Efficacy of Peritoneal Drainage for Focal Intestinal Perforation

Shunsuke Watanabe1*; Tatsuya Suzuki1; Yasuhiro Kondo1; Atsuki Naoe1; Naoko Uga1; Toshihiro Yasui1; Fujio Hara1; Masafumi Miyata2; Hiroko Boda2; Tetsushi Yoshikawa2

1. Department of Pediatric Surgery, Fujita Health University Hospital, Aichi, Japan, 2. Department of Pediatric, Fujita Health University Hospital, Aichi, Japan

Correspondence: *. Correspondence: Shunsuke Watanabe, Department of Pediatric Surgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan. E-mail: E-mail:


Abstract

Objective:

Focal intestinal perforation (FIP), which is characterized by the lack of inflammatory infiltration peripheral to the perforation, develops with few premonitory symptoms. The treatment typically involves laparotomy for drainage or percutaneous drain insertion. We retrospectively investigated the efficacy and risks associated with laparotomy-assisted drainage and peritoneal drainage (PD) for FIP.

Study Design:

This was a retrospective, comparative study.

Results:

We retrospectively evaluated seven infants with FIP who were admitted to the neonatal intensive care unit between April 2007 and March 2017. Five infants were administered indomethacin and six were administered steroids. The PD group had significantly higher birth weight, higher C-reactive protein (CRP) levels, and shorter operating times. In addition, they gained weight postoperatively but often required adjuvant therapy for bowel function. There was no significant difference between the groups regarding the time to post-operative full feeding, and all infants showed improved physical appearance.

Conclusions:

PD under local anesthesia can be considered for treating infants with FIP who have elevated CRP levels and poor general condition. We think management of this condition is still challenging in our experience, and it is necessary to continue in the future.

Received: 2018 January 9; Accepted: 2018 March 22

J Neonatal Surg. 2018 ; 7(2): 20
doi: 10.21699/jns.v7i2.724

Copyright

Copyright: © 2018, Watanabe et al

Keywords: C-reactive protein, Extremely low birth weight infant, Focal intestinal perforation, Peritoneal drainage.

INTRODUCTION

With recent advances in perinatal care, there has been an increase in the number of low birth weight infants who suffer from neonatal diseases. Due to their prematurity, extremely low birth weight infants (ELBWIs) have a particularly high incidence of complications that are known to affect their lifetime prognosis. Gastrointestinal perforation is one such complication. In Japan, the mortality rate of neonates with gastrointestinal perforation was 18.9% in 2013, exceeding the rate of 16.9% in 2008, which is said to be due to increased birth and survival rates of ELBWIs, coupled with a simultaneous increase in the incidence of gastrointestinal perforation [1].

Gastrointestinal perforations that occur during the neonatal period include necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) without necrotic changes [2]. FIP is alternatively called as intestinal perforation, local intestinal perforation, isolated intestinal perforation [3,4], or spontaneous intestinal perforation [5].

NEC is presumed to cause intestinal necrosis when a pathogen enters the intestinal tract and triggers an excessive immune response because of the prematurity of the neonate’s intestinal structure and intestinal immunity and proliferation of abnormal intestinal flora [6]. Pathologically, FIP is characterized by loss of muscle layer without inflammation or ischemia. In addition, due to the intestinal prematurity of neonates, the administration of steroids or indomethacin (e.g., for patent ductus arteriosus repair) is indicated when Candida or Staphylococcus epidermidis is the causative pathogen [7].

Early treatment for gastrointestinal perforation includes peritoneal drainage (PD) surgery and drainage with laparotomy; however, indications for these procedures and their therapeutic effects are not completely known. Ein et al. first reported PD surgery for NEC in 1977 [8], and various reports have been published since then, including subsequent treatment plans [9-11]. Cass et al. had reported on PD surgery for FIP in 2000 [12].

We therefore conducted a retrospective comparative investigation of the efficacy and risks of drainage with laparotomy versus PD for early treatment of infants with FIP who were hospitalized in our neonatal intensive care unit (NICU) between April 2007 and March 2017. For PD performed in our hospital, indwelling Penrose drains were inserted at two sites (the foramen of Winslow and pouch of Douglas) under local anesthesia supplemented with neuroleptanalgesia in NICU.

MATERIALS AND METHODS

A total of 1737 infants were admitted to our NICU from April 2007 to March 2017. In this study, we included 102 ELBWIs among the 1560 infants with complete medical records, including sex, gestational age, birth weight, and 5-min Apgar score. FIP diagnosis was based on the infant’s clinical course and plain radiographic findings. In total, seven (6.8%) of 102 ELBWIs had FIP and were included in the study. We investigated the following characteristics in these seven infants with FIP (Figure 1): Sex, gestational age, birth weight, 5-min Apgar score, indomethacin administration, steroid administration, day of onset of gastrointestinal perforation, white blood cell count and C-reactive protein (CRP) level at onset, blood gas pH, operating time, time to post-operative full feeding, use of adjuvants for bowel function, and treatment outcomes.


[Figure ID: F1] Figure 1. Study design (April 2007–March 2017)

Moreover, we consulted with pediatric department about the general condition before treatment and decided it. The criteria of the poor general condition were infant’s appearance, work of breathing, and circulation to skin.

RESULTS

Table 1 summarizes ELBWIs who developed FIP, whereas Table 2 summarizes patient characteristics. The infants included four boys and three girls. The median gestational age was 25.2 weeks (24.1–28.6 weeks), mean birth weight was 767 g (660–965 g), mean 5-min Apgar score was 8 (5–9), and there was one case of maternal transport. Overall, indomethacin was administered to 71.4% of the infants and steroids to 85.7%. Six infants received pre-operative enteral nutrition. The median time to onset of gastrointestinal perforation was 5 days (3–8 days) after birth. All infants had abdominal distension, but none had bloody feces. The median white blood cell count was 14.0 µL−1 (4.7–32.1 µL−1), median CRP was 0.64 mg/dl (0.3–1.1 mg/dl), and median pH was 7.31 (7.21–7.39). The CRP levels were higher in the PD group than in the laparotomy and enterostomy (Lap+Ent) group. The median operating time was 36 min (15–106 min); five infants underwent PD for the first surgery, and two underwent laparotomy and enterostomy. The PD group had shorter operating times. The ascites culture of one infant showed Alcaligenes xylosoxidans and Burkholderia cepacia.

Table 1. Summary of extremely low birth weight infants who developed focal intestinal perforation

Table 2. Details of the extremely low birth weight infants who developed focal intestinal perforation

The median time to full feeding was 28 days (24–38 days), with no significant difference between the PD and Lap+Ent groups during the post-operative clinical course. All four infants requiring Daikenchuto for the purpose of improving gastrointestinal motility or enemas as adjuvant treatment for post-operative bowel function belonged to the PD group. One infant transitioned from PD to Lap+Ent group. One infant in the PD group died 6 months after the surgery because of respiratory failure due to chronic lung disease.

We compared post-operative weight gain in the PD and Lap+Ent groups; at both 1 and 3 months postoperatively, the PD group showed better weight gain than that by the Lap+Ent group (Figure 2).


[Figure ID: F2] Figure 2. Comparison of post-operative weight gain in the peritoneal drainage group and the enterostomy with laparotomy group

DISCUSSION

The incidence of FIP in ELBWIs weighing <1000 g at birth is <3–7% [5,13,14]. In our hospital, the incidence of FIP in ELBWIs was 6.8%, which was comparable to the reported rate [5,13,14]. In contrast to the reported gestational age (26.9 weeks) and birth weight (981 g) of ELBWIs with FIP [15], the gestational age was lesser (25.2 weeks) and birth weight was lower (767.0 g) in our hospital.

FIP in ELBWIs could be caused by maternal factors, including chorioamnionitis [16], but factors associated with infant prematurity must also be considered. According to Stavel et al., although there was a correlation between FIP and indomethacin administration, there was no correlation between FIP and early enteral nutrition [17]. In addition, five of the seven infants (71.4%) in our study developed FIP following indomethacin administration, and one infant who did not receive enteral nutrition developed FIP (Figure 2). Steroid administration is known to be markedly effective in ELBWIs with late-onset circulatory collapse, which is common in patients with chronic lung disease [18]. Hence, steroids are often administered from birth. In our study, six of the seven infants (85.7%) were administered steroids (Figure 2) and subsequently developed FIP. Based on these results, one of the causes of FIP could be reduced blood flow to the intestinal mucosa due to indomethacin administration and damage to the intestinal mucosa due to steroid administration. Consequently, it is vital to continue investigation of this condition as few ELBWIs have FIP.

Laparotomy has been the conventional treatment for gastrointestinal perforation in ELBWIs, but PD surgery for NEC was reported in 1977 [8]. Furthermore, there was a report in 2000 on PD surgery for FIP [12]. Since then, PD has been preferred as the initial surgical procedure in smaller babies in unstable condition because the beliefs that these babies may not tolerate laparotomy, although the benefits of laparotomy procedures, including enterostomy, are still under discussion [19]. In a Japanese report, PD was performed in 15% of patients with FIP compared with enterostomy in 55%, which included 15% of those undergoing gastrointestinal resection and 8.2% undergoing simple perforation closure [15].

Some reports have shown no significant difference in the prognosis between PD and laparotomy as the initial surgery for gastrointestinal perforation [19]; however, those who undergo PD sometimes require post-operative laparotomy. Moreover, there is no significant difference in the time to post-operative full feeding between PD and laparotomy as the initial surgery for gastrointestinal perforation [20]. In our study, 71.4% of infants with FIP underwent PD, which was higher than the normal proportion. One infant in the PD group who could not tolerate post-operative enteral nutrition underwent Lap+Ent. Hence, post-operative laparotomy may be sometimes required after initial PD.

We found no significant difference in the time to post-operative full feeding between the PD and Lap+Ent groups, which was consistent with previously reported findings. There were more ELBWIs with FIP in the PD group in our hospital because when the general condition of an infant is determined to be poor based on an elevated CRP level following perforation, and PD is the first surgical option due to the shorter operating time and low level of invasiveness. This study showed that PD is a valid option because of the lack of differences between the two procedures.

A Japanese study reported that the mortality rate of infants with FIP was 20.6% [15]. To date, all but one of the seven infants in our study have survived. The infant who did not survive died due to acute exacerbation of chronic lung disease at 6 months of age, indicating that there was no difference in the prognosis for the two surgical techniques. Postoperatively, the PD group gained weight more rapidly. Although there was no difference between the groups for initiating oral feeding in our study, the Lap+Ent group had an intestinal fistula, which is thought to create malabsorption issues, including post-operative diarrhea, short bowel syndrome, and not absorbed nutrition in the anal digestive tract.

More infants in the PD group required post-operative adjuvants for bowel function (Table 2), which was possibly due to tissue, such as omentum, attaching to the perforation during the healing process after PD [21], with the adhesion possibly impeding enterokinesis.

The limitation of this study was the small number of patients. Hence, further investigation on PD for treating FIP is warranted.

CONCLUSION

PD is effective for treating FIP in LBWIs. We found no significant difference between the PD and Lap+Ent groups regarding the time to post-operative full feeding. PD under local anesthesia supplemented with neuroleptanalgesia can be used because it is less invasive and has a shorter operating time compared with Lap+Ent. Therefore, when an infant’s general condition is poor, and the CRP level is elevated after perforation, it is considered to be an effective method for improving the condition of such infants. We think that management of this condition is still challenging in our experience, and it is necessary to continue in the future.


Conflicts

Conflict of interest: None

Source of Support: Nil

REFERENCES
1. Japanese Society of Pediatric Surgeons–Academic and Advanced Medical Care Investigative Committee. Current State of Japan's Neonatal Surgery–2013 National Meeting on Neonatal Surgery. J Jpn Soc Pediatr Surg 2015 51:1234–45.
2. Okuyama, H. Kubota, A. Oue, T. Kuroda, S. Ikegami, R. Kamiyama, M. Acomparison of the clinical presentation and outcome of focal intestinal perforation and necrotizing enterocolitis in very-low-birth-weight neonates. Pediatr Surg Int 2002 18:704–6.
3. Blakely, ML. Lally, KP. McDonald, S. Brown, RL. Barnhart, DC. Ricketts, RR. Postoperative outcomes of extremely low birth-weight infants with necrotizing enterocolitis or isolated intestinal perforation:A prospective cohort study by the NICHD neonatal research network. Ann Surg 2005 241:984–9.
4. Blakely, ML. Tyson, JE. Lally, KP. McDonald, S. Stoll, BJ. Stevenson, DK. Laparotomy versus peritoneal drainage for necrotizing enterocolitis or isolated intestinal perforation in extremely low birth weight infants:Outcomes through 18 months adjusted age. Pediatrics 2006 117:e680–7.
5. Shah, TA. Meinzen-Derr, J. Gratton, T. Steichen, J. Donovan, EF. Yolton, K. Hospital and neurodevelopmental outcomes of extremely low-birth-weight infants with necrotizing enterocolitis and spontaneous intestinal perforation. J Perinatol 2012 32:552–8.
6. Neu, J. Walker, WA. Necrotizing enterocolitis. N Engl J Med 2011 364:255–64.
7. Gordon, PV. Understanding intestinal vulnerability to perforation in the extremely low birth weight infant. Pediatr Res 2009 65:138–44.
8. Ein, SH. Marshall, DG. Girvan, D. Peritoneal drainage under local anesthesia for perforations from necrotizing enterocolitis. J Pediatr Surg 1977 12:963–7.
9. Moss, RL. Dimmitt, RA. Barnhart, DC. Sylvester, KG. Brown, RL. Powell, DM. Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation. N Engl J Med 2006 354:2225–34.
10. Hull, MA. Fisher, JG. Gutierrez, IM. Jones, BA. Kang, KH. Kenny, M. Mortality and management of surgical necrotizing enterocolitis in very low birth weight neonates:A prospective cohort study. J Am Coll Surg 2014 218:1148–1155.
11. Federici, S. DE, BL. Straziuso, S. Leva, E. Brisighelli, G. Mattioli, G. Multicenter retrospective study on management and outcome of newborns affected by surgical necrotizing enterocolitis. Minerva Chir 2017 72:183–7.
12. Cass, DL. Brandt, ML. Patel, DL. Nuchtern, JG. Minifee, PK. Wesson, DE. Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation. J Pediatr Surg 2000 35:1531–6.
13. Emit, S. Ahmad, I. Davis, K. Sills, JH. Risk factors for spontaneous intestinal perforation in extremely low birth weight infants. Open Pediatr Med J 2008 2:11–5.
14. Wadhawan, R. Oh, W. Vohr, BR. Saha, S. Das, A. Bell, EF. Spontaneous intestinal perforation in extremely low birth weight infants:Association with indometacin therapy and effects on neurodevelopmental outcomes at 18-22 months corrected age. Arch Dis Child Fetal Neonatal Ed 2013 98:F127–32.
15. Sato, M. Hamada, Y. Kohno, M. Ise, K. Uchida, K. Ogata, H. Neonatal gastrointestinal perforation in japan:A nationwide survey. Pediatr Surg Int 2017 33:33–41.
16. Ragouilliaux, CJ. Keeney, SE. Hawkins, HK. Rowen, JL. Maternal factors in extremely low birth weight infants who develop spontaneous intestinal perforation. Pediatrics 2007 120:e1458–64.
17. Stavel, M. Wong, J. Cieslak, Z. Sherlock, R. Claveau, M. Shah, PS. Effect of prophylactic indomethacin administration and early feeding on spontaneous intestinal perforation in extremely low-birth-weight infants. J Perinatol 2017 37:188–93.
18. Arai, I. Kamamoto, T. Izaki, K. Nishikubo, T. Takahashi, Y. Investigation about the late-onset circulatory collapse (LCC) in extremely-low-birth-weight infants. J Jpn Soc Premature Newborn Med 2010 22:39–43.
19. Rees, CM. Eaton, S. Kiely, EM. Wade, AM. McHugh, K. Pierro, A. Peritoneal drainage or laparotomy for neonatal bowel perforation? A randomized controlled trial. Ann Surg 2008 248:44–51.
20. Mishra, P. Foley, D. Purdie, G. Pringle, KC. Intestinal perforation in premature neonates:The need for subsequent laparotomy after placement of peritoneal drains. J Paediatr Child Health 2016 52:272–7.
21. Diesen, DL. Skinner, MA. Spontaneous sealing of a neonatal intestinal perforation by the omentum. J Pediatr Surg 2008 43:2308–10.

Refbacks

  • There are currently no refbacks.




Copyright (c) 2018 Shunusuke Watanabe, Tatsuya Suzuki, Yasuhiro Kondo, Atsuki Naoe, Naoko Uga, Toshihiro Yasui, Fujio Hara, Masafumi Miyata, Hiroko Boda, Tetsushi Yoshikawa

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

The Journal of Neonatal Surgery has been indexed Google Scholar, NewJour, Open J-gate, Science Central, eDoctoronline, Ulrichsweb, Scirus, JournalTOCs, ResearchGate, Scribed, FreeJournalAct, Anoox, News-Digest, CORE.

EL-MED-Pub Publishers